1.3

Historical developments in
Health EDRM policy andresearch: the case study ofJapan
Authors
Shinichi Egawa, Hiroyuki Sasaki, Anawat Suppasri, Hiroaki Tomita
and Fumihiko Imamura, International Research Institute of Disaster
Science (IRIDeS), Tohoku University, Sendai, Japan.
Fuji Nagami, Tohoku Medical Megabank Organization, Tohoku
University, Sendai, Japan.
Yasuhiro Kanatani, Department of Clinical Pharmacology, Tokai
University School of Medicine, Isehara, Japan.
Akiko Eto, Department of Health Crisis Management, National Instituteof Public Health, Wako, Japan.
Yuichi Koido, Disaster Medical Assistant Team Secretariat, National
Disaster Medical Center, Tokyo, Japan.
Tatsuhiko Kubo, Department of Public Health and Health Policy,
Hiroshima University, Hiroshima, Japan.
Hiroshi Kato, Hyogo Institute for Traumatic Stress, Kobe, Japan.
Yoshiharu Kim, National Center for Neurology and Psychiatry, Kodaira,Japan.
Sonoe Mashino, Research Institute of Nursing Care for People andCommunity, University of Hyogo, Akashi, Japan.
Ryoma Kayano, WHO Centre for Health Development, Kobe, Japan.

1.3.1 Learning objectives
To understand the importance of research evidence for Health EDRM
policy and practice, considering Japan as a case study, in order to be able
to:

16

1.

Review historical examples of disaster impact and response relevant
to health.

2.

Discuss how changes in health risks and resilience affect disaster
impacts, and how disasters affect health risks.

3.

Explain improvements in the methods used to assess and minimize
health impacts of disasters.

WHO Guidance on Research Methods for Health Emergency and Disaster Risk Management

1.3.2 Introduction
Disaster risk, which is defined as “the potential loss of life, injury, or
destroyed or damaged assets which could occur to a system, society or acommunity in a specific period of time, determined probabilistically as afunction of hazard, exposure, vulnerability and capacity” (1). This definitionof risk can apply to all types of hazardous events, including emergencies
and disasters. These events are the outcome of the conditions of risk, thatis the interrelationship between hazard, exposure, vulnerability andcapacity, that are present in a community. This relationship can be
expressed as follows:
Risk ∝ function (hazard,exposure,vulnerability,capacity)
Disaster risk management relates to efforts to either reduce the hazards,
exposure and vulnerability, increase the capacities, or do both.
As a disaster-prone country, Japan has developed a disaster risk reduction(DRR) policy and programme to manage the risks of the large-scaledisasters it has experienced through its history, which include
earthquakes, tsunamis, typhoons, floods and volcanic eruptions. Although
the occurrence of a natural hazard largely depends on geographical andclimate conditions, the impact of an event depends not just on the event’s
magnitude, but also on vulnerabilities and socioeconomic conditions suchas poverty and social development (2). Poor infrastructure and limited
disaster risk management lead to higher numbers of deaths, injuries andillnesses in the affected population (3–6).The amounts of missing andout-of-date data that reflect the social development and stability of each
community should be considered when calculating the overall risk (2, 7–8).
After the onset of a disaster, communities need to put an enormous effort
into response, recovery, rehabilitation and reconstruction, as well as into
reducing risks and anticipating or preparing for the next hazard event.
These cyclical events can spiral into higher levels of risk and worse
situations in future unless the aim of “Building Back Better” is achieved, butwill worsen if this fails. Research and investment in Health EDRM provide
an important means of identifying and managing the risk through thesespiral cycles of disasters, and so are identified as priorities in the Sendai
Framework (9).
This chapter shows how the environment for conducting Health EDRM
research has improved in Japan as a result of historical events (10) (seeCase Study 1.3.1), and with the transformation and expansion of thecountry’s disaster medical system (see Case Studies 1.3.2 to 1.3.7). Theseexperiences are also relevant to policy and programme development inother countries.

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1.3

Case Study 1.3.1
Using the history of disasters to understand disaster risk
Japan has a long history of preserving documents: the oldest historical
record of a tsunami is from the 869 Sanriku Earthquake at Japan Trench,with an estimated magnitude of 8.6 (11). The affected area, Tohoku in thenortheast of Japan, has since been affected by several more earthquakes
and tsunamis, including the 1611 Sanriku Earthquake, and has
experienced magnitude 7 earthquakes every 30 to 40 years. In addition,
the 1960 Valdivia Earthquake in Chile led to a tsunami that killed 142
people and affected nearly 150 000 more in Japan (Figure 1.3.1). Theselevel 2 tsunamis occur every 400 to 800 years, and evacuation has usually
been the only way to survive (12). More recently, the region has improved
its risk management of earthquakes and tsunamis, by building
earthquake-proof housing and longer and taller sea walls, and by drawing
on community tradition to educate people to evacuate after strong
shaking. Although the 2011 Great East Japan Earthquake resulted in morethan 20 000 deaths and displaced 480 000 people, the level ofvulnerability reduction and capacity building was not in vain. For
instance, seismic-proof buildings that did not collapse and high seawalls,
such as that in Taro Town, Iwate Prefecture (13), along with early warning
systems and the tradition of self-evacuation behaviour (14) all helped toreduce the number of victims.
Figure 1.3.1 History of earthquakes and tsunami in the pacificcoastal line of Tohoku area, Japan
869
Sanriku
Earthquake

RS(M)

1611
Sanriku
Earthquake

2011
Great East Japan
Earthquake

10
9.5

1960
Tsunami from Chile

98.5
8Pacific coastal lineof Tohoku Area

7.5
7

Miyagi earthquake inevery 30-40 years

6.5
6

800

1000

1200

1400
Year

Key
Earthquake with tsunami
Tsunami without earthquake
Earthquake without tsunami.

18

1600

1800

2000

WHO Guidance on Research Methods for Health Emergency and Disaster Risk Management

Although tsunamis occurred only in the western Pacific and Indian Ocean
from 1970 to 2016, (Figure 1.3.2-A), in the 370 years from 1600 to 1969,
major tsunamis had occurred in all areas of the world (Figure 1.3.2-B). Thisshows the importance of assessing and understanding hazards via
historical events, and not relying solely on recent experiences.
Figure 1.3.2 Simulated maximum tsunami amplitude (adaptedfrom (15))
A: 1970 to 2016 (47 years)
2004 Sumatra
2011 Tohoku

2010
Chile

Events from 1970 to 2016

Amplitude (m)B: 1600 to 1969 (370 years)
1755
Lisbon1707
Nankai1700
Cascadia
1843
Guadeloup

1960
Chile

Events from 1600 to 1969

Amplitude (m)

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1.3

1.3.3 Large-scale disasters prompt policy changes toaddress health needs
On 1 September 1923, the Great Kanto Earthquake struck the Tokyo
metropolitan area and more than 100 000 people were trapped incollapsed buildings or killed by fire. As a consequence, the building code
first enacted in 1920 was modified in 1924 to triple the mechanical safety
factor. After World War II, Japan experienced several earthquakes andtyphoons that killed thousands of people (Figure 1.3.3), leading theGovernment of Japan to establish the Disaster Countermeasures Basic Act
in 1961 (Act No. 223 of 15 November 1961; revised June 1997) and todevelop comprehensive and systematic disaster risk management as anational priority (16). Under the Disaster Countermeasures Basic Act, theGovernment of Japan prepares an annual report, the White Paper, which
provides an overview of disasters in Japan, various statistical data anddisaster management measures taken by the Government (17).
The building code was revised again several times during the twentiethcentury, to include regulations to increase lateral seismic coefficient,
strengthen reinforced concrete, and set allowable unit stress andhorizontal load bearing capacity using evidence from surveillance andresearch on damaged buildings in earthquakes. After many buildings
collapsed in the 1995 Great Hanshin Awaji Earthquake, the current versionof the building code was enacted in 2000, requiring buildings to be able toendure at least one violent shake.
The building standard for nuclear reactors was established in 1981 andfurther modified in 2006. This requires nuclear reactors to be fixed to firmrock bed and countermeasures for possible tsunami inundation. After the
1979 Three Mile Island nuclear power plant incident in the United States ofAmerica (USA), the Japan Nuclear Safety Committee established theDisaster Measure around Nuclear Power Plant (Nuclear Emergency
Response Guideline) in 1980. Then, after the 1999 Tokaimura critical
nuclear incident, that guideline was revised and renamed “Disaster
Measure around Nuclear Facility” in 2000. The Nuclear Regulation
Authority enforced the current Nuclear Emergency Response Guideline in2013, after the 2011 Great East Japan Earthquake and Fukushima nuclear
power plant incident (18).

20WHO Guidance on Research Methods for Health Emergency and Disaster Risk Management

Figure 1.3.3 Number of deaths in natural disasters in Japan
DisasterCountermeasures
Basic Act

1945
MikawaEq 2306
Makurazaki
Tph 3756

1896
Sanriku
Tsunami 22,000

1923
Great Kanto
Eq 105,000

100,000

1995
Great Hanshin
Awaji
Eq 6,437

2018
West Japan
Heavy Rain 245

1948
Fukui
Eq 3769

2016
Kumamoto
Eq 2731959
IsewanTph 5098

2011
Great East JapanEq 21,839

10,000

2018

2014

2010

2006

2002

1998

1994

1990

1986

1982

1978

1974

1970

1966

1962

1958

1954

1950

1946

1891

100

1933

1,000

Key: Eq: earthquake, Tph: Typhoon.
The number of deaths in the 1995, 2011 and 2016 earthquakes include disasterrelated deaths. Adapted from White Paper of Disaster Management (19).

On 17 January 1995, the Great Hanshin Awaji Earthquake (magnitude 7.3)
struck the densely populated Kobe City and surrounding area. It caused
6437 deaths and injured nearly 44 000 people, and led to the concept of“preventable disaster death”, which is defined as “death occurring during adisaster that would have been preventable under normal conditions ofregional health systems” (20). Analyses of the deaths found that 83.3%
resulted from crush injuries due to the collapse of buildings and 12.8%
were from burns (22). This highlighted the main medical needs in the acutephase (within three days after the onset of the disaster), which were for thetreatment of trauma, such as crush syndrome, and severe burns (22–23).
However, meeting these needs was especially difficult because 97.8% of
the 180 hospitals and 84.0% of the 1809 clinics were damaged (23) (seeCase Studies 1.3.2 to 1.3.4).

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1.3

Case Study 1.3.2
Development of disaster nursing support system
The widespread damage to medical facilities caused by the 1995 Great
Hanshin Awaji Earthquake meant that many hospitals and clinics wereunable to function. Nurses were one of the main frontline health workers
to provide medical support to survivors, but they were also greatly
affected by the earthquake themselves. In order to provide the necessary
surge capacity, the Japan Nursing Association (JNA) called on volunteer
support nurses from across Japan and sent hundreds of nurses to theaffected area. The Japan Nursing Association collaborated with Hyogo
Nursing Association and the College of Nursing Art and Science Hyogo tocoordinate the matching and allocation of volunteer nurses, based on thehealth needs of local communities. Volunteer nurses were sent tohospitals, elderly care homes and evacuation shelters to serve vulnerable
populations, to screen for health problems among evacuees and to
improve hygiene in the evacuation shelters.
Following this experience, the Japan Nursing Association established thevolunteer nurses dispatching system for the response to disasters. Local
nursing associations provide training to nurses willing to support thissystem and, once they qualify, register them as a Disaster Support Nurse.
This system has worked well in several large-scale disasters, including
the 2004 Niigata Chuetsu Earthquake, when 400 nurses were dispatchedand the 2011 Great East Japan Earthquake, when 3770 nurses weredispatched (24).
To support this initiative by the Japan Nursing Association, Japanese
academia has developed disaster nursing capacity building. A national
survey in 2005 found that approximately one in nine Nursing Schools inJapan had an independent subject of disaster nursing and 46% included
disaster nursing as a part of other subjects (25–26). Globally, theInternational Council of Nurses (ICN) and WHO have developed theInternational Council of Nurses Framework of Disaster Nursing
Competencies (27), which is being used to educate and train nursing
students and professionals around the world (28).

Case study 1.3.3
Development of an acute mental health support system

22

Since 1995, the Government of Japan has organized annual workshops fordisaster mental health, including treatment for Post-Traumatic Stress
Disorder (PTSD), which have been attended by 12 000 mental healthprofessionals. Each local prefectural government appointed theparticipants to contact when there is a need for mental trauma care in an
emergency situation. The Government also tasked the National Center for
Neurology and Psychiatry with developing a national guideline forcommunity mental health treatment in disasters. This states that mostpsychological symptoms after a disaster are natural, common andtransient reactions; that psychological debriefing was not proven to beeffective for preventing PTSD, and that Psychological First Aid (PFA) was
the most recommended psychosocial counter measure immediately aftera disaster. The guideline was distributed to every local government inWHO Guidance on Research Methods for Health Emergency and Disaster Risk Management

Japan as a basic national principle for the management of post-disastermental health and has been translated into Thai and Indonesian.
In Japan, under the Disaster Relief Act, it is the governor of an affected
local government who is responsible for requesting assistance andrescue from central and other local governments. Since 1995, this has
included the dispatch of mental health care teams, composed of
psychiatrists, nurses, psychologists, social workers and clerks, whousually rotate over one or two weeks. In the 2011 Great East Japan
Earthquake, 57 teams including 3419 members were sent to disasterareas, and worked in close collaboration with the local prefectural andmunicipal mental health and welfare centres (29–30).

Case Study 1.3.4
Development of a long-term mental health support system
As well as establishing a system for acute-phase mental health response
after disasters, Japan has also developed a long-term mental healthsupport system for survivors of large-scale disasters (31–32). In responseto the need for mental health support among the survivors of the 1995
Great Hanshin Awaji Earthquake, a traumatic stress care centre wasestablished five months after the earthquake and the Disaster-Affected
People Assistance Programme was implemented. This provided nearly 21000 mental health consultations including more than 17 000 outreachvisits and nearly 5000 group activities for survivors during its first five
years. In 2004, the centre was reorganized as the Hyogo Institute ofTraumatic Stress, becoming the first institute in Japan specializing in
PTSD treatment, research and training (33).
Building on the work of this centre, mental health care centres for longterm psychosocial support were also established following the 2004
Niigata Chuetsu Earthquake, the 2011 Great East Japan Earthquake andthe 2016 Kumamoto Earthquake. The mental health care centre for the2004 Niigata Chuetsu Earthquake provided more than 9000 consultations
for more than 16 000 survivors in ten years. Three mental health care
centres were established after the 2011 Great East Japan Earthquake; in
Iwate, Miyagi and Fukushima. In collaboration with local municipalities
and local academia, each centre has provided specialized care andsupport based on local needs, including outreach support, in-house
consultation, mental health support for healthcare providers, advocacy
for local communities and capacity building. These initiatives alsoenabled long-term follow up of people at risk of mental health disease,providing important data for research, such as that discussed in Chapters
2.1 and 5.1.

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1.3

1.3.4 The National Disaster Medical System
The experiences of the Great Hanshin Awaji Earthquake described in Case
Studies 1.3.2 to 1.3.4 prompted Japan to initiate its National Disaster Medical
System. This comprises four components to enhance surge capacity for
health response during and after disasters, which are shown in Table 1.3.1.
Table 1.3.1 Components of the Japanese National Disaster Medical
SystemDisaster basehospital

As of May 2019, 743 tertiary hospitals (with multiple hospitals in each of the
47 prefectures in Japan) are designated as disaster base hospitals, with thefollowing requirements:

₋ Seismic-proof structure₋ Emergency supply of power, water, medical gas
₋ Emergency department, intensive care unit and heliport.
₋ Business continuity plan (added in April 2019)
Disaster base hospitals provide a centre of disaster response in thedesignated area and host a Disaster Medical Assistance Team (DMAT),
composed of its employees, to support affected hospitals. Outside ofdisasters, disaster base hospitals provide education in disaster medicine tohealth professionals. The recently added requirement for a business
continuity plan aims to strengthen emergency power, water and medical
supply based on experience in recent disasters that caused disruption ofbasic service. All disaster base hospitals had implemented a business
continuity plan by August 2019 (34).
Disaster Medical
Assistance Team(DMAT)DMATs are teams of specially trained medical professionals comprising up to
five members, including medical doctors, nurses and logisticians, who areable to work together using a single car. As of April 2017, there are more than
1500 teams registered across all prefectures in Japan. In principle, a DMAT
would arrive at the affected area within 24 to 48 hours, under the commandand control of DMAT headquarters. DMATs assist affected hospitals, healthand welfare facilities, municipal headquarters and manage Staging Care
Units (SCU) for wide area transportation, including hospital evacuation. DMAT
members update their knowledge and skills through periodic training (35) andtheir education programme was revised after the 2011 Great East Japan
Earthquake to focus more on communication, coordination and hospital
support, including hospital evacuation (36).
The initial concept of DMAT was developed in the USA, and the Japaneseversion of DMAT and Emergency Medical Information System (EMIS) havebeen implemented in many medical facilities (37).

24

Staging Care
Unit (SCU) andwide areatransportation

To reduce the number of preventable disaster deaths, Staging Care Units(SCU) are used to select patients who will be transported to non-affectedareas. SCUs are often based at an airport close to the affected area andsupport coordination between medical responders and transportation
agencies. The role of SCU with limited resources can be flexible according to
the situation (36–38).

Emergency
MedicalInformation
System (EMIS)

EMIS is used to share real-time information among fieldworkers,
headquarters and central government. It collects, frequently updates andshares information about the function of disaster base hospitals and otherhospitals in the affected area, the status of evacuation centres, field
hospitals, DMATs, and road and airport conditions for transportation. The
updated headquarters activity plan and record are also shared through EMIS
(37–38). EMIS was updated after the 2011 Great East Japan Earthquake toincorporate a geographical information system (GIS) (see Chapter 4.8) inorder to allocate the hospitals, clinics, welfare centres and DMATs in realtime on a single map to improve efficient data sharing and decision making.

WHO Guidance on Research Methods for Health Emergency and Disaster Risk Management

The Japanese National Disaster Medical System improved the healthresponse to disasters and was successfully implemented in several largescale disasters after its establishment. However, the Great East Japan
Earthquake on 11 March 2011 (magnitude 9.0) that affected a wide area ofnortheast Japan, causing many tsunamis over 10 meters high and leading
to 22 252 deaths and 6233 injured people, identified further health needs,
especially in relation to the care of vulnerable populations.
As of October 2011, of 380 medical facilities in the three most affected
coastal prefectures (Iwate, Miyagi, Fukushima), 191 had totally or partiallylost their ability to have in-patients and 205 facilities were completely or
partially unable to accept out-patients. Ten facilities were completely
destroyed and 290 facilities were partially destroyed (21). The large size ofthe affected area, the wide variety of population needs and the range ofassistance available made clear the need for disaster medical coordinators(39). For instance, disruption to haemodialysis as a result of loss ofelectricity and water was an emergent threat to life, and so the network of
medical doctors related to haemodialysis collaborated successfully withDMAT to organize the large-scale evacuation of 80 haemodialysis patientsfrom the Kesennuma area of Miyagi Prefecture to Hokkaido and 581
patients from the Fukushima Prefecture (154 to Niigata, 382 to Tokyo and
45 to Chiba), providing temporary dialysis before transfer if necessary (40).
This led to the inclusion of haemodialysis liaison as an additional
component of the National Disaster Medical System.
In the acute phase after the earthquake, particular challenges included
providing support for damaged psychiatric hospitals and ensuring safety,
food and medicine for hundreds of their hospitalized patients. Althoughsome mental health professional teams voluntarily supported the affectedareas, effective support was difficult to implement because of the lack ofclear reporting lines or collaboration agreements (41). In response to theneed for mental health support for affected people and damaged facilities,
the Disaster Psychiatric Assistance Team (DPAT) was established in 2013
(42–43).
Government facilities and the public health workforce were also severely
damaged in the 2011 Great East Japan Earthquake. A total of more than
140 000 person days were provided by external local municipality officials
to support the affected areas, but the damage to facilities and the loss ofofficials meant that the host municipalities lost much of their management
and coordination capability and could not effectively allocate or utilize thelimited resources (44). Therefore, to address the surge needs for publichealth and logistical management, Disaster Health Emergency AssistanceTeams (DHEAT) were developed.
In addition, further health needs, including evacuation support and followup rehabilitation for disabled people and the need for special considerationand follow up for maternal and child health were also highlighted in the
management of evacuations. These and other follow-up activities resulted
in the development of the Japan Disaster Rehabilitation Assistance Team(JRAT) and Mother and Child Health Liaison.
Another of the significant gaps during the 2011 Great East Japan
Earthquake was the lack of any standard medical record form for
emergency medical teams. Teams from different organizations used

25

1.3

different forms, making it difficult for them to share clinical information.
This failure in continuity of care led to the creation of the Joint Committee
for Disaster Medical Record of Japan, which proposed a standard disastermedical record form (45). A special feature of this standard recording
format is its inclusion of a daily medical report function called J-SPEED (seeTable 1.3.2 and Case Study 1.3.5).
The earthquake also highlighted the concept of “disaster-related death”(46). According to the Government of Japan’s Reconstruction Agency, as of
21 August 2012 some 1950 people who had initially survived theearthquake and tsunami were confirmed dead due to disaster-induced
fatigue, psychological trauma or the aggravation of existing chronic
diseases. This concept was further highlighted in the 14 April 2016
Kumamoto Earthquake (magnitude 6.5) where nearly 80% of deaths (218out of 273, as of 12 April 2019) fell into this category (46). As aconsequence, the SPHERE standard (47) is increasingly applied to theenvironmental improvement of evacuation shelters and to the lives ofaffected people to try to reduce these deaths that are not directly causedby the disaster.
Along with the developments in health response to disasters in Japandescribed above, there have also been important innovations to improve
preparedness for better health response in the acute phase (Case Study
1.3.5) and research to increase health resilience in affected areas (CaseStudies 1.3.6 and 1.3.7).

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WHO Guidance on Research Methods for Health Emergency and Disaster Risk Management

Table 1.3.2 Additional components of the Japanese National
Disaster Medical System introduced after the 2011 Great East
Japan Earthquake
Disaster medical
coordinators

Disaster medical coordinators are officially appointed by prefectures andcoordinate the activities of external and internal medical assistance teams tomaximize their impact on the medical and public health needs of affected
populations through close communication with local stakeholders. Following an
initial initiative in Hyogo Prefecture after the 1995 Great Hanshin Awaji
Earthquake, by 2011 only four prefectures had designated a disaster medical
coordinator but, by 2015, 43 out of 47 prefectures (91%) had designated or wereplanning to designate such a coordinator (39).

Disaster
Psychiatry
Assistance Team

Disaster Psychiatry Assistance Teams (DPAT) assist psychiatric hospitals andsupport surge mental health needs in affected areas after disasters byassessing the local psychiatric needs and collaborating with DMAT and otherassistance teams and local psychiatric facilities to provide high quality
psychiatric medicine (43). With the support of the DPAT Secretariat, DPAT
members update their knowledge and skills through periodic training (44).

Disaster Health
Emergency
Assistance Team

Disaster Health Emergency Assistance Teams (DHEAT) assist the
management function of the public health sector in affected local
municipalities, through information collection, integration, analysis and sharing
with fieldworkers. Local municipalities (prefectures, special assigned cities
and political areas) are recommended to organize Disaster Health
Emergencies Assistance Teams with public health professionals (48-50). The
operation plan has been developed since 2014 and has been available on the
Ministry of Health, Labour and Welfare website since March 2018. Sixteen
local municipalities dispatched Disaster Health Emergencies AssistanceTeams to the areas affected by the 2018 West Japan Heavy Rain (44).

Japan Disaster
Rehabilitation
Assistance TeamJapan Disaster Rehabilitation Assistance Teams (JRAT) assist, in particular,
older people and people with disability from the very early phase ofevacuation. JRATs promote conversation with evacuated people, set up slopes
and handrails in the evacuation centre or in temporary houses, and provide
care and supervision. JRATs also provide temporary support devices and aids
to promote rehabilitation of affected people.

Mother andChild Health
Liaison

Paediatricians and obstetricians join the disaster medical headquarters team
to coordinate mother and child health issues, including perinatal care andmental and physical support of children.

Haemodialysis
LiaisonPhysicians network to identify people who need haemodialysis in the affectedarea and coordinate their transportation to areas outside the affected region.
This can include the provision of transitional temporary haemodialysis before
patients are sent to more distant hospitals (40).

Standard
disaster medical
record /J-SPEED

The disaster medical record has been standardized and all emergency medical
teams use it regardless of their organization. This makes it easier to transfer
clinical information among medical providers for continuity of patient care.
One special feature of this standardization is a daily medical report function
called J-SPEED (see Case Study 1.3.5).

27

Case Study 1.3.5
Development of health data management systems
Timely and effective data collection during and after a disaster is key forbetter health response (see Chapter 4.4) and is a large challenge fornational Emergency Medical Teams (EMTs) such as DMAT (51). Having
experienced these problems after the 2011 Great East Japan Earthquake,a joint committee was established and started a project to develop astandardized format for medical data collection to support effective
information collection, sharing and analysis for the following response.
This format was developed with reference to the Surveillance in Post
Extreme Emergency and Disaster (SPEED) system, developed by WHO
and the Ministry of Health of the Philippines (52) (see Chapter 2.2).
The newly developed format, referred to as the Japanese version ofSPEED (J-SPEED) includes health conditions such as certain chronic
diseases, which are more common in Japan (53). It was successfully usedby all national EMTs during recent disasters in Japan, including gathering
medical data from 8089 consultations during the 2016 Kumamoto
Earthquake, 3620 consultations during the 2018 West Japan Heavy Rainsand 591 consultations during the 2018 Hokkaido earthquake. It enabled
rapid assessment of the health needs of affected people and significantly
contributed to the identification of people who required referrals to
specialist teams, acute mental health support (who were referred toDPAT), and other specific health responses (54).
This progress has taken place alongside the development of the WHO
Emergency Medical Team (EMT) Minimum Data Set (MDS), a standardized
medical data collection and reporting system adopted in 2017.

Case Study 1.3.6
Cohort studies to evaluate longitudinal effects of a disaster on
affected communities
Many cohort studies have been designed and conducted to evaluate
longitudinal effects of the 2011 Great East Japan Earthquake on theaffected communities. These studies were established as a collaborative
effort between local governments and academic institutes in the affected
regions to better understand the health condition of residents. Care andfollow-up activities were undertaken to improve the health condition of
the affected communities based on the outcome of the surveys.
For example, the Fukushima Health Management Survey is conducted by
the Fukushima Prefectural Government and the Fukushima Medical
University to alleviate residents’ concerns over radiation and facilitate
appropriate health care of residents in the Fukushima Prefecture. The
surveys assess longitudinal health conditions of people who lived in the
Prefecture between 11 March and 1 July 2011 (55-56).

28

As another example, the Center for Community Health was established in
Tohoku University to assess the longitudinal effect of the earthquake on
affected communities in Ishinomaki city, Shichigahama town and Sendai
City (57). The Shichigahama Health Promotion Project was designed andconducted as a collaboration between Shichigahama town and Tohoku

WHO Guidance on Research Methods for Health Emergency and Disaster Risk Management

University. The project team conducted annual surveys and follow-up of
all residents whose houses suffered major damage (58).
Knowledge accumulated from these activities can be useful not only for
improving the health of residents affected by this specific disaster, butalso for reducing exposure and vulnerability, disaster preparedness,
response to, and recovery from future disasters. Similarly, using the sameor a similar format for the collection of health information for people
affected by future disasters will support research consistency and should
facilitate ethical approval (see also Chapters 3.4 and 6.4).

Case Study 1.3.7
Long-term follow up using registers and biological data
Tohoku University is one of Japan’s leading national universities and islocated in the area affected by the 2011 Great East Japan Earthquake. It
initiated the Tohoku Medical Megabank Project in order to restore
community medical services in the areas heavily damaged by thisearthquake and tsunami disaster, and to establish an advanced medical
system to meet the global trend towards large-scale medical information
technology. The project is executed in corporation with Iwate Medical
University and funded by the national Government of Japan.
The earthquake caused catastrophic damage not only to health facilities
but also to the health workforce in the Tohoku District. While thereconstruction of health facilities was implemented relatively successfully
with support for infrastructure reconstruction, there was a notable decline
in the number of medical professionals in Tohoku. This became alarmingly
severe in more recent years and recruiting health professionals to work in
the re-constructed medical facilities became critical. This urgent need led
to a unique project to develop a centre of future-oriented medical
services in Tohoku and to make this a driver for attracting medical
practitioners.
Through the Tohoku Medical Megabank Project, an integrated biobank
was established of biospecimen and information from cohort studies
focused on the effect of the disaster on health (59). There are two initialcohort programmes in the Tohoku Medical Megabank Project: (i) the Birthand Three-Generation Cohort Study and (ii) the Community-Based Cohort
Study. Both are predominantly targeting the earthquake-affected areasand consist of multiple components including genomic studies. Alongwith assessment of the effects of the disaster, participants in thesestudies can contribute to other independent biomedical research toaddress knowledge gaps relating to differences between those with andwithout the same illness who lead the same lifestyle, and differences
between individuals who are responsive or non-responsive to various
forms of exposure. Several reports from the project have already clarified
the influence of the disaster on vulnerable populations (60). This project
has enabled the long-term follow up of biomedical aspects of disasteraffected people, as well as promoting large-scale research moregenerally, which will use the voluntary contributions of the study
participants to address other areas of uncertainty.
29

1.3

In Japan, the national Government’s disaster management policies are
decided by the Central Disaster Management Council, which is chaired by thePrime Minister and includes all Cabinet members. During and after a largescale disaster, the Cabinet Office is engaged in the collection anddissemination of accurate information, reporting to the Prime Minister,
establishment of the emergency activities system (including the Government’s
Disaster Management Headquarters), and the overall wide-area coordinationof disaster response measures. DRR has been carried out using the concept
of “Building Back Better” through consultation with scientific experts to help
with prediction of hazards, assessment and reduction of exposure andvulnerability, and building of response capacity (17).
Improvements to the National Disaster Medical System is a key part of DRR.
Research into Health EDRM is promoted by a grant-in-aid from the JapaneseSociety for Promotion of Science, Ministry of Education, Culture, Sports,
Science and Technology (MEXT) and the Ministry of Health, Labour andWelfare of Japan, while the budget for implementing countermeasures andresponse comes from the Cabinet Office. Awareness of these mechanisms forresearch promotion and implementation among researchers is also promoted
in order that science and technology can be used to enhance DRR.

1.3.5 Conclusions
The long history of large-scale disasters in Japan and the substantial
events of recent decades have provided the country with many opportunities
to learn from the past to improve Health EDRM for the future. This has
made use of evidence from research of many different types, and has led
to the implementation of the National Disaster Medical System. This has
continued to be refined as new evidence has accumulated, helping toensure that disaster risk management, including prevention, preparedness,
response and recovery, make an important contribution to the health of thenation, and encouraging partnerships between policy makers, practitioners
and researchers to lead to further improvements in the future.

1.3.6 Key messages

30

oHealth EDRM requires the continual enhancement of policies
and programmes using both historical evidence and up-to-date,reliable, scientific evidence from research. This requires highquality research, which needs capacity building in researchmethods and timely, accurate and appropriately collected data.

oThis chapter featured Japan as an example of applying theprinciple of Building Back Better through its spiral cycles ofdisasters. The development of health systems and the healthworkforce over time in response to the health needs identified inemergencies and disasters has improved data collection,
assisted the management of survivors and produced a better
environment for research and subsequent policy making.

oThis chapter illustrates how policy development and theenhancement of health systems have built on evidence frombefore, during and after emergencies and disasters in Japan, andprovides a practical example for other countries.

WHO Guidance on Research Methods for Health Emergency and Disaster Risk Management

1.3.7 Further reading
Hazards and health:Menne B, Murray V, editors. Floods in the WHO European Region: healtheffects and their prevention. 2013. http://www.euro.who.int/en/
publications/abstracts/floods-in-the-who-european-region-health-effectsand-their-prevention (accessed 7 February 2020).
History and perspective of disasters:
Burkle FM. Challenges of Global Public Health Emergencies: Developmentof a Health-Crisis Management Framework. Tohoku Journal of
Experimental Medicine. 2019: 249(1): 33-41.
International framework:
WHO Health Emergency and Disaster Risk Management Framework.
https://apps.who.int/iris/bitstream/handle/10665/326106/9789241516181eng.pdf (accessed 7 February 2020).
Kayano R, Chan EY, Murray V, Abrahams J, Barber SL. WHO thematic
platform for health emergency and disaster risk management research
network (TPRN): Report of the Kobe Expert Meeting. International Journalof Environmental Research and Public Health. 2019: 16(7): 1232.
UN/ISDR and WHO. Bangkok principles to implement the health aspects of
Sendai Framework for Disaster Risk Reduction 2015–2030. 2016. https://www.preventionweb.net/files/47606_
bangkokprinciplesfortheimplementati.pdf (accessed 7 February 2020.
Disaster Medical Needs and Responses in Japan
Suda T, Murakami A, Nakamura Y, Sasaki H, Tsuji I, Sugawara Y et al.
Medical Needs in Minamisanriku Town after the Great East Japan
Earthquake. Tohoku Journal of Experimental Medicine. 2019: 248(2): 73-86.

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